Provider Demographics
NPI:1497249817
Name:ALEXANDER VILLICANA MD LLC
Entity Type:Organization
Organization Name:ALEXANDER VILLICANA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLICANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-447-6641
Mailing Address - Street 1:PO BOX 90577
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91109-0577
Mailing Address - Country:US
Mailing Address - Phone:626-447-6641
Mailing Address - Fax:626-447-3423
Practice Address - Street 1:624 W DUARTE RD STE 201
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-9261
Practice Address - Country:US
Practice Address - Phone:626-447-6641
Practice Address - Fax:626-447-3423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA216272086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA21627OtherCA MEDICAL LICENSE